Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 159-161

Peroneal nerve palsy due to pseudoaneurysm following total knee arthroplasty: A case presentation


1 Division of Vascular and Endovascular Surgery, Department of Surgery, Christian Medical College and Ludhiana, Ludhiana, Punjab, India
2 Division of Vascular Surgery, Christian Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission22-Apr-2021
Date of Acceptance13-May-2021
Date of Web Publication20-Jan-2022

Correspondence Address:
Pranay Pawar
Division of Vascular Surgery, Christian Medical College and Hospital, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_38_21

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  Abstract 


Total knee arthroplasty (TKA) is among the commonly performed orthopedic procedures with a very good safety profile. Vascular injuries following TKA are very rare and usually identified intraoperatively or in the immediate postoperative period. Popliteal artery pseudoaneurysms post-TKA are very rare, and their management can be quite challenging. We describe a case that presented more than 3 months after the index surgery with a peroneal nerve palsy due to a pseudoaneurysm.

Keywords: Bypass surgery, popliteal artery pseudoaneurysm, total knee arthroplasty, vascular injury


How to cite this article:
Solomon JS, Pawar P, John B, Luther A. Peroneal nerve palsy due to pseudoaneurysm following total knee arthroplasty: A case presentation. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:159-61

How to cite this URL:
Solomon JS, Pawar P, John B, Luther A. Peroneal nerve palsy due to pseudoaneurysm following total knee arthroplasty: A case presentation. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Aug 16];8, Suppl S2:159-61. Available from: https://www.indjvascsurg.org/text.asp?2021/8/6/159/336020




  Introduction Top


Vascular injuries are rare in patients undergoing total knee arthroplasty (TKA) with a reported incidence in the range of 0.03%–0.17%.[1] Popliteal artery pseudoaneurysm is either asymptomatic or late in presentation and is often life threatening at presentation. A major reason for delay in diagnosis is because it is often misdiagnosed as deep vein thrombosis or a compartment syndrome.[2] Certain studies have indicated that the individual incidence of peroneal nerve palsy after TKA varies from 0% to 9.5%. Conditions associated with peroneal nerve injury after TKA include flexion contracture, valgus deformity, postoperative epidural analgesia, external leg compression, increased tourniquet duration, postoperative hematoma, and history of nerve root compression.[3] We report a case of popliteal artery pseudoaneurysm that presented 3 months following TKA, which was unusual in presentation, its diagnosis, and management.


  Case Report Top


A 46-year-old female presented to the vascular surgery Outpatient Department with difficulty in flexion of the right knee and foot drop post-TKA. She had undergone a right TKA under spinal anesthesia approximately 3 months before presentation at another hospital. She developed foot drop a week after surgery and was given a foot drop splint to support and encourage dorsiflexion of the ankle and prevent an equines deformity, along with exercises to improve range of movement of the knee joint and the ankle joint. On examination, the patient was overweight with a BMI of 29.3 and presented with gross swelling of the right lower limb. Postarthroplasty scars and fullness of the popliteal fossa were noted. She did not have any tenderness on palpation, but there was a palpable thrill and painless restriction of the range of motion of the knee. She was able to flex the knee joint up to 60°. The distal peripheral pulses of the right lower limb were absent, and the limb was cool as compared to the opposite side. There was an audible bruit over the right popliteal fossa. An ultrasound Doppler of the popliteal fossa revealed a to-and-fro movement of blood within a cavity suggestive of a pseudoaneurysm of the popliteal artery [Figure 1]. Computed tomography (CT) angiography of the bilateral lower limbs showed a heterodense collection of approximately 8 cm × 4.5 cm × 6.5 cm in the posterior aspect of the right knee joint with contrast pooling and direct communication with the right popliteal artery confirming the diagnosis of a popliteal pseudoaneurysm [Figure 2].
Figure 1: Ultrasonography Doppler showing to-and-fro motion of blood in the sac suggestive of pseudoaneurysm (Ying-Yang sign)

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Figure 2: Computed tomography angiography showing displaced popliteal artery with a filling defect suggestive of pseudoaneurysm

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She was taken up for an open surgical repair of the popliteal artery through a posterior approach. The plane was deepened taking care to preserve the tibial and peroneal nerves, which were intact but stretched. The proximal popliteal artery and the distal tibioperoneal trunk were identified and looped. The aneurysm sac was approximately 8 cm × 6 cm × 8 cm and had grossly altered the local anatomy [Figure 3]. After vessel control and heparin administration, the sac was opened and the clots evacuated. The pressure by the sac had caused necrosis of the mid-popliteal artery, resulting in a 5 cm defect. A 6 mm externally ringed polytetrafluoroethylene graft was used to bypass the defect in an end-to-end fashion from the proximal popliteal to the tibioperoneal trunk. A prosthetic graft was used, as her saphenous vein was sclerosed and not suitable, even in the contralateral leg. A suction drain was placed above the sac, and the wound was closed in layers. Her postoperative recovery was unremarkable and she was discharged on dual antiplatelet and physiotherapy. She has been on regular follow-up for the last 1 year and is doing well. Her ankle movements have markedly improved and triphasic flow is present in the posterior tibial and peroneal artery with an ankle-brachial pressure index of 0.8 [Figure 4].
Figure 3: Intraoperative image showing pseudoaneurysm sac

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Figure 4: Intraoperative image showing a ringed polytetrafluoroethylene bypass graft from proximal popliteal artery to tibioperoneal trunk

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  Discussion Top


Popliteal artery pseudoaneurysm is a rare, but a dangerous complication noted following TKA.[2] In the cases reported by Agarwala et al. and by Shin et al., the diagnosis was made within a week of surgery.[1],[3] In our case, the patient presented almost 3 months postsurgery with foot drop as the presenting complaint. The plausible explanation for this is that the gradual expansion of the pseudoaneurysm led to stretching of the peroneal nerve, which manifested as foot drop.

The majority of vascular injuries during TKA involve the popliteal artery. There are few studies describing injury to geniculate arteries during TKA.[4] Based on anatomical damage and cause, Papadopoulos et al. classified the causes of vascular injuries as follows:

  1. Occlusion: Which can be due to thrombosis, due to vascular wall damage, and low blood flow as a result of tourniquet application, microtears, endothelial damage, and stretching of the vessels during manipulations of the knee. The application of bone cement may also lead to thrombosis. Another rare cause of arterial occlusion is compression of the popliteal artery by the knee implant
  2. Embolization by calcified plaques
  3. Popliteal artery sharp transection during the cuts
  4. Arteriovenous (A-V) fistula formation
  5. Aneurysm or more commonly pseudoaneurysm formation.[5]


Rubush described the danger zone for popliteal artery injury during tibial cuts or placement of Hohmann retractors. He compared the articular surface of tibia to a clock considering the 6 o'clock position as the most anterior position. The danger zone is between 11 and 3 o'clock.[6] The proximity of the popliteal artery to the posterior tibial surface renders it vulnerable to injury. The distance from the posterior tibial surface has been measured at 0.96–3.15 mm during 0°–90° of right knee flexion.[7]

Popliteal artery pseudoaneurysm is often misdiagnosed initially as deep vein thrombosis following surgery. Patients are often initially started on anticoagulants, but when there is no resolution of edema in the leg, patients are evaluated further.[1],[8] The initial imaging investigation used for diagnosis is a duplex ultrasound of the leg. CT angiography of the bilateral lower limbs helps confirm the diagnosis and better delineate the anatomy.[9]

Pseudoaneurysm of the popliteal artery can be approached by multiple methods, depending on the acuity of presentation. Ultrasonography (USG)-guided compression repair with or without thrombin injection can be tried in patients who have small pseudoaneurysms with small defects. Using the USG transducer, compression is applied at the neck of the pseudoaneurysm. This is done in two settings, a week apart. The treatment causes compression of the pseudoaneurysm but allows arterial flow to the distal aspect of the lower limb.[1] In open surgeries, pseudoaneurysm is either treated by primary repair of the tear in case of small defects or by interposition/bypass with a vein or synthetic graft when the defect is more than 2 cm. Open bypasses are associated with better long-term patencies as compared to endovascular therapy. In some cases, where the artery is not salvageable due to infection, above knee amputation may need to be performed. Recent advances in management of the pseudoaneurysm include endovascular surgery. A covered stent graft is placed within the popliteal artery at the site of the tear, which excludes the pseudoaneurysm from the circulation.[9],[10]

In our case, since the pseudoaneurysm was very large and leading to peroneal nerve palsy, we decided to proceed with an open repair. Stenting would have been associated with significant radial compression on the stent, leading to luminal compromise and subsequent thrombosis, without relieving the peroneal nerve palsy.


  Conclusion Top


Popliteal artery pseudoaneurysm is an uncommon complication noted following a TKA. Our patient is a rare presentation of pseudoaneurysm of the popliteal artery, leading to peroneal nerve compression, which manifested as foot drop almost 90 days after TKA. Maintaining a high index of clinical suspicion in patients following TKA with persistent lower limb edema that does not resolve with time, a detailed clinical evaluation, and CT angiography as confirmatory imaging modality is mandated for diagnosis of pseudoaneurysm and is worth considering. Open surgical or endovascular repair of pseudoaneurysm can be considered definitive management options.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Agarwala SR, Mohrir GS, Dotivala SJ. Posttraumatic pseudoaneurysm of popliteal artery following total knee arthroplasty. Indian J Orthop 2013;47:101-3.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Ammori MB, Evans AR, Mclain AD. Popliteal artery pseudoaneurysm after total knee arthroplasty. J Arthroplasty 2016;31:2004-7.  Back to cited text no. 2
    
3.
Shin YS, Hwang YG, Savale AP, Han SB. Popliteal artery pseudoaneurysm following primary total knee arthroplasty. Knee Surg Relat Res 2014;26:117-20.  Back to cited text no. 3
    
4.
Shaw A, Stephen A, Lund J, Bungay P, Denunzio M. Geniculate arterial pseudoaneurysm formation following trauma and elective orthopaedic surgery to the knee: 2 case reports and a review of the literature. J Radiol Case Rep 2009;3:12-6.  Back to cited text no. 4
    
5.
Papadopoulos DV, Koulouvaris P, Lykissas MG, Giannoulis D, Georgios A, Mavrodontidis A. Popliteal artery damage during total knee arthroplasty. Arthroplast Today 2015;1:53-7.  Back to cited text no. 5
    
6.
Rubash HE, Berger RA, Britton CA, Nettrour WS, Seel MJ. Avoiding neurologic and vascular injuries with screw fixation of the tibial component in total knee arthroplasty. Clinical Orthopaedics and Related Res 1993;(286):56-63.  Back to cited text no. 6
    
7.
Farrington W, Charnley G, Harries S. The position of the popliteal artery in the arthritic knee. J Arthroplasty 1999;14:800.  Back to cited text no. 7
    
8.
Geertsema D, Defoort KC, van Hellemondt GG. Popliteal pseudoaneurysm after total knee arthroplasty: A report of 3 cases. J Arthroplasty 2012;27:e1-4.  Back to cited text no. 8
    
9.
Sloan K, Mofidi R, Nagy J, Flett MM, Chakraverty S. Endovascular treatment for traumatic popliteal artery pseudoaneurysms after knee arthroplasty. Vasc Endovascular Surg 2009;43:286-90.  Back to cited text no. 9
    
10.
Woolgar JD, Reddy DS, Robbs JV. Delayed presentation of traumatic popliteal artery pseudoaneurysms: A review of seven cases. Eur J Vasc Endovasc Surg 2002;23:255-9.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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